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 DOI: 10.1177/1524839913494786

published online 22 July 2013Health Promot PractDonald L. Rubin, Vicki S. Freimuth, Sharon D. Johnson, Terry Kaley and John Parmer

Training Meals on Wheels Volunteers as Health Literacy Coaches for Older Adults  

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Health Promotion PracticeMonth XXXX Vol. XX , No. (X) 1 –7DOI: 10.1177/1524839913494786© 2013 Society for Public Health Education

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Homebound older adults constitute a “hardly reached” population with respect to health communication. Older adults also typically suffer from health literacy challenges, which put them at increased risk of adverse health outcomes. Suboptimal interactions with provid-ers are one such challenge. Interventions to improve interactive health literacy focus on training consumers/patients in question preparation and asking. Meals on Wheels volunteers are uniquely suited to coach their clients in such interaction strategies. Seventy-three Meals on Wheels volunteers participated in workshops to train as health literacy coaches. The 3- to 4-hour workshops included units on communicating with older adults, on the nature of health literacy, and on the process of interactive health literacy coaching. Participants viewed and discussed videos that modeled the targeted communication behaviors for older adult patients interacting with physicians. They role-played the coaching process. After 9 months, coaches partici-pated in a “booster” session that included videos of ideal coaching practices. Evaluation questionnaires revealed that participants had favorable reactions to the workshops with respect to utility and interest. They especially appreciated learning communication skills and seeing realistic videos. A measure of knowledge about the workshop material revealed a significant increment at posttest. Fidelity of coaching practices with respect to workshop curriculum was confirmed. This training in interactive health literacy for commu-nity-based lay volunteers constitutes one way to imple-ment the National Action Plan to Improve Health

Literacy for one “hardly reached” population. An online tool kit containing all workshop materials is available.

Keywords: aging; health literacy; patient education; training

This article describes workshops for training community-based volunteers—Meals on Wheels (MOW) drivers in this instance—to promote the

health literacy skills of homebound older adults in rural and urban settings. Many audiences for health promotion and risk communication have been charac-terized as “hard to reach,” as if it were their choice to be socially isolated or to experience barriers in access to health information (Freimuth & Mettger, 1990). These groups should more likely be referred to as “hardly reached,” because we typically fail to bring to bear the full potential of community resources in con-veying messages to members of such vulnerable popu-lations

494786 HPPXXX10.1177/1524839913494786Health Promotion PracticeRubin et al. / Training Health Literacy Coaches2013

1University of Georgia, Athens, GA, USA2Oregon State University, Jackson, OR, USA3Morrison Healthcare Food Services, Atlanta, GA, USA4Centers for Disease Control and Prevention, Atlanta, GA, USA

Training Meals on Wheels Volunteers as Health Literacy Coaches for Older Adults

Donald L. Rubin, PhD1

Vicki S. Freimuth, PhD1

Sharon D. Johnson, MS2

Terry Kaley, MA3

John Parmer, PhD4

Authors' Note: The project reported here was funded by the National Institute on Aging (Grant RO1G034073 to Vicki Freimuth, PI). All opinions expressed are solely those of the authors. Address correspondence to Donald L. Rubin, University of Georgia, Coverdell Building, Suite 107, Athens, GA 30602-7394, USA; e-mail: drubin@uga.edu..

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One population that suffers from being “hardly reached” by public health communication campaigns comprises homebound older adults. Channels by which public health messages might reach older adults are often overlooked by health campaigns (Kay, Crittenden, & Charland, 2008). Lessons learned from natural disas-ters indicate that older adults are at particular risk of being omitted from health communication plans. Reaching them effectively requires collaboration with networks of community service providers (Aldrich & Benson, 2008; Beattie, Whitelaw, Mettler, & Turner, 2003). Moreover, older adults—particularly those in isolated rural locations—are even in the best of times vulnerable to isolation from the social support that is crucial for their physical and mental health (Cornwall & Waite, 2009).

Healthy People 2020 (U.S. Department of Health and Human Services, 2010), the nation’s public health agenda, recognizes limited health literacy as an issue of national significance and sets objectives and targets for improvement. Health literacy is a complex interaction among patients/consumers, providers, and health care systems, but a commonly used definition describes it as “the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions” (Berkman, Davis, & McCormack, 2010, p.16). Improving health literacy is increasingly critical as information, choices, and decisions about health care and public health have become more complex (e.g., Zarcadoolas, Pleasant, & Greer, 2006). Navigating today’s health care system often demands a savvy and highly health literate patient or consumer. Proliferation of technologies that support rapid dissemination of information, promotion efforts of the health care industry such as direct-to-consumer advertising, and the move toward a more patient-driven care model are increasingly shifting the balance of available health information from the pro-vider to the patient. As the amount of available health information continues to rapidly increase, there is an implicit expectation that patients can understand and use this information to reduce health risks and make informed decisions that protect their health. Yet it is clear that the health literacy capacities of the vast majority of Americans are inadequate to these purposes, and health care providers and systems have largely failed to meet their information-processing needs. Thus, an Institute of Medicine (2004) report concluded that 9 out of 10 adults have difficulty using crucial everyday health information such as warning labels on drugs (Davis et al., 2006).

The challenges of making sense of health informa-tion are especially great for the increasing proportion of

people 65 years and older in the United States (U.S. Department of Health and Human Services, 2007). Older adults need strong health information–seeking and –processing skills because they are more likely to suffer from chronic diseases and comorbidities, which result in a daunting array of information needs and decision-making challenges. These challenges are intensified for older adults due to typical decrements in cognitive, hearing, language, and reading capacities that impair health literacy (Baker, Gazmararian, Sudano, & Patterson, 2000).

Nearly half of all older adults display inadequate or marginal health literacy (Miller et al., 2007). Depressed levels of health literacy in this population are directly related to poor mental health and quality of life (Wolf, Gazmararian, & Baker, 2005) and ultimately to mortal-ity (Baker et al., 2007). The linkage between poor health literacy and poor health status among older adults stems from various sources. For example, older adults are at risk of poor communication with their clinicians (Schillinger, Bindman, Wang, Stewart, & Piette, 2004). In particular, they are often disinclined to ask questions or to request clarification, even when they do not understand what a provider is telling them (Callahan et al., 2004; Greene, Adelman, & Majerovitz, 1996). Such low levels of engagement and question asking in clinical encounters are characteristic of inad-equate health literacy (Katz, Jacobson, Veledar, & Kripalani, 2007). Thus, there is strong warrant for deploying public health resources to promote better communication between clinicians and older adults.

Improving health literacy, especially with “hardly reached” populations, demands a multilateral approach that at once enhances provider communication, simpli-fies health information, renders health care systems easier to navigate, and also fosters information-seeking and -processing skills for patients and consumers (Parker & Ratzan, 2010). Interventions to foster health literacy skills among older adults in particular have typically occurred in clinical settings. For example, prior to a medical appointment, older patients may be provided with a workbook or a nurse educator may converse with them in order to prepare an account of symptoms and a list of questions (Cegala, Post, & McClure, 2001; Robinson & Whitfield, 1985). A broader public health approach to health literacy, however, devises interventions beyond just clinical settings (Nutbeam, 2000). Partnering with community-based service organizations can mitigate the “hardly reached” status of older adults with respect to public health interventions (Beattie et al., 2003). Organizations that provide home-based health services, including health education and information (Goldman & Schmalz, 2008),

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are clearly well suited for reaching homebound older adults with health literacy interventions (for health literacy interventions delivered at rural senior center hubs, see Young, Weinert, & Spring, 2012).

MOW volunteers have daily welcomed contact with their clients and are thus promising candidates to serve as health literacy educators for “hardly reached” home-bound older adults. The Meals on Wheels Association of America (http://www.mowaa.org/about) estimates that a volunteer “army” of between 800,000 and 1.7 million Americans deliver well over 1 million meals each day. Over 5,000 MOW agencies function in remote rural communities, in inner cities, and everywhere in between. MOW drivers are welcome visitors who often have considerable access to older adults’ homes. They generally have ongoing contact with their clients and therefore can assess changes in those clients’ mental and physical health status (Johnson, 2004). MOW vol-unteers also have the potential to coach new behaviors for their clients over time. Previous MOW participation in public health campaigns includes an initiative to install smoke alarms and educate clients about fire pre-vention (CDC at Work, n.d.).

In light of the need for enhancing older adults’ health literacy skills, and recognizing the unique poten-tial of MOW volunteers to serve as skills coaches for that hardly reached population, a project was under-taken to train MOW drivers to assume that role. This article describes the context, content, and evaluation of the workshops that were administered to train these community volunteer trainers. Information about the elements of the coaching intervention that was admin-istered to the MOW clients is presented only as it bears on the design of the workshops for coaches.

>>WorksHoP Context

Six nutritional services agencies in rural counties of southwest Georgia, along with three agencies serving inner-city clients in metropolitan Atlanta, partnered in this project. The directors of each agency recruited MOW drivers who displayed stability with the organi-zation and who expressed motivation to engage in an enriched volunteer experience. In all, 73 MOW volun-teers participated in health literacy coach training workshops. Seventy-eight percent of the volunteers worked at urban MOW programs. Fifty-nine percent were persons of color. Their average age was 52 years (SD = 14.98), and average years working with MOW was 5.85 (SD = 5.81). The coaches displayed high health literacy. On the Short Test of Functional Health Literacy for Adults (Baker, Williams, Parker, Gazmararian, & Nurss, 1999), the median score was 35

out of a maximum possible score of 36, and the mean was 34.33 (SD = 2.48).

Training consisted of an initial workshop, followed by a “booster” about 9 months later (see content description below). Training workshops were con-ducted in groups as large as 22 but were also frequently administered to individuals. The initial sessions lasted 3 to 4 hours; the booster required about 1 hour. Participants received gasoline expenses plus small incentive payments.

>>WorksHoP Content

Since older adults are at risk of poor communica-tion with their clinicians, coach training was designed in particular to help volunteers foster interactive health literacy among their elderly clients. Interactive health literacy—as opposed to health literacy for print materials—is the process of exchanging health infor-mation in interpersonal encounters, especially between providers (or other information sources) and patients/consumers (see Rubin, Parmer, Freimuth, Kaley, & Okundaye, 2011). The program for which the MOW volunteers were being trained focused mainly on the importance of formulating questions and empowering clients to ask them during medical appointments (Agency for Healthcare Quality and Research, n.d.). The coaching workshops utilized principles of adult learning theory, including experiential learning and uses of concrete narratives (Merriam, 2001). They encompassed three components: (a) skills for commu-nicating with older adults, (b) information about health literacy, and (c) mechanics of health literacy coaching. All materials for these workshops can be found online at http://chrc.uga.edu/research/toolkit/. Those online workshop materials include full slide presentations, video examples, and instructions for role-playing activities, along with sample recruitment flyers. The amount of time dedicated to each component varied with the size of the workshop group and the engage-ment of the participants. As a rule of thumb, however, about 1 hour was devoted to communication skills, 30 minutes to health literacy background information, and 90 minutes to the coaching process.

Communicating With Older Adults

A rural community demonstration funded by the Northwest Health Foundation and launched in south-ern Oregon in 2002 laid the groundwork for using MOW drivers as health literacy coaches. Maximizing Brief Encounters (Johnson, 2004) provided an eight-workshop series designed and taught by faculty of the

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Oregon State University Extension Service. Workshops were held weekly over a 2-month period. Each lasted 1 hour. Separate sessions were dedicated to each of the following topics: (a) communicating effectively with older adults, (b) relating to older adults with sensory impairment, (c) understanding age-related memory loss and dementia, (d) identifying medication management problems in older adults, (e) recognizing and respond-ing to depression, (f) understanding and avoiding food-borne illness, (g) making the home environment safer, and (h) becoming familiar with community resources. In the Oregon trials, pre- and posttest interviews indi-cated that MOW volunteers retained substantial infor-mation from most of the modules. Accordingly, the communication module, together with elements from the memory loss and medication management mod-ules, was incorporated into the health literacy coaching workshops.

A communication tool developed as a component of the training used the acronym “OLiVeR” (Observe, Listen, Validate, Respond/Refer). Volunteers were instructed how to maintain a respectful and “active listening” communication style. They were taught how to improve their observational skills and encouraged to use “I” messages (e.g., “I worry about that scatter rug by the door. I’d like to relocate it so nobody slips and falls”) rather than “You” messages (e.g., “You should get rid of that rug or you’ll fall”).

In addition, the communication training component of these workshops reinforced the importance of older adults engaging in active question asking (Butow, Dunn, Tatersall, & Jones, 1994; Cegala et al., 2001). This section of the training introduced coaches to the Ask-Me-Three patient protocol—What is my main problem? What do I need to do about it? Why is it important for me to do that? (see Galiher et al., 2010; Mika, Wood, Weiss, & Treviño, 2007; Wisconsin Collaborative for Healthcare Quality, 2010). As part of this element of the communication training, participants viewed and dis-cussed videos of older adults using this protocol at a physician office visit.

Health Literacy Knowledge

The second section of the workshop attempted to contextualize the coaching activity in a broader arena of health literacy. The purpose of that contextualiza-tion was twofold. First, we hoped that knowledge of health literacy would motivate the MOW volunteers to see how the coaching on which they were about to embark was a constructive response to solve large national issues in health care quality and social equity. Second, we hoped that the coaches would integrate

health literacy principles into their own health care repertoires.

Information presented about health literacy in the United States included (a) a definition of health liter-acy; (b) the prevalence of low health literacy, espe-cially among older adults; (c) the consequences of low health literacy for health status; (d) the association between poor health literacy and shame; (e) relations between health literacy and informed consent for medical procedures; and (f) effective ways to enact health literacy.

Logistics of Health Literacy Coaching

The final component of the workshop explained and provided practice in the actual health literacy coaching tasks. Coaches in this program had a number of tasks to accomplish: (a) delivering print and other materials to their clients, (b) helping clients use a calendar to track their medical appointments, (c) showing two videos that modeled interactive health literacy behaviors for older adults, and (d) helping clients prepare questions and formulate concerns for upcoming medical appoint-ments. At the training workshops, volunteers reviewed a sample checklist that they could use to document the date they completed specific activities with their cli-ents. Training continued with demonstrating how to operate the portable DVD players. The first role-modeling video for clients, “Three Little Questions Your Health Care Professional Wants You to Ask,” was shown, and the presenter discussed the script for debriefing the video with clients. Next, staff played the second mod-eling video, “How to Make Sure You Get Answers to Good Questions for Good Health,” and talked about the postvideo script for discussion. Coaches were paired up to swap roles as coach and client in role-playing scenarios. Finally, participants filled out workshop evaluations and other instruments that measured their knowledge of health literacy and communication prac-tices with older adults.

To assure that coaches were adhering to the coach-ing protocol once the project had been underway, a booster training was conducted about 9 months follow-ing the initial training workshops. During the first part of the booster training, coaches were encouraged to tell stories about their coaching experiences. They then viewed a video, “How to coach for Health Literacy,” that models an ideal health literacy coaching encounter between a volunteer and her client. Participants com-pared their own coaching experiences with the video vignettes. They also discussed how their clients could overcome barriers they encountered in using the ques-tioning protocols during their medical appointments.

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The booster sessions generally lasted 1 hour and were administered to coaches individually or in pairs.

>>WorksHoP evaluation

Questionnaire Results

To evaluate the workshop, participants were first asked to mark four Likert-type items for which responses ranged from 0 (not at all) to 8 (a great deal). Means and standard deviations were as follows: “I learned new information . . . about communicating with older adults”: M = 6.63, SD = 1.09; “This work-shop will help me do my . . . assignment better”: M = 6.75, SD = 0.98; “This workshop was well planned”: M = 6.67, SD = 1.06; and “This workshop was con-ducted well”: M = 6.88, SD = 0.86.

Next, participants were asked to rate the workshop along certain traits using four 7-interval semantic dif-ferential scales. Means and standard deviations were as follows: “practical-theoretical”: M = 1.94, SD = 1.63; “engaging-boring”: M = 1.97, SD = 1.50; “innovative-traditional”: M = 2.02, SD = 1.30; “detailed-general”: M = 1.82, SD = 1.48. Mean values for both Likert-type and semantic differential items were thus all located well within the regions of positive valence.

Learning from the workshop was assessed in two ways. First a 19-item test (Cronbach’s α = .873) previ-ously developed for the Oregon Maximizing Brief Encounters program (Johnson, 2004) was administered after the workshop. An example of a true/false question is “Older adults typically need dosages that are one third to one half of the dosage for a younger adult.” The average score was 68% correct (SD = 0.22). In addition, participants were asked to recall the three questions from the Ask-Me-Three protocol. Scores, which could range from 0 to 4, averaged 1.73 (SD = 1.29) prior to the workshop presentation and 2.48 (SD = 1.01) following the workshop. The increase from pretest to posttest on this knowledge test was statistically significant (t

70 =

3.57; p < .001).

Qualitative Results

Following the workshop, participants were asked, “What was the highlight of the workshop?” Fifty-two responses were obtained from the 73 participants. Of these, 13 individuals made explicit reference to the communication component of the training (e.g., “learn-ing to approach the clients,” “role ‘I’ plays in helping clients”). Twelve individuals explicitly mentioned the value of watching the videotaped depictions of interac-tive health literacy between an older adult and her

physician (e.g., “The video showed how patient bene-fits”). Ten comments were general statements that the workshop would enable participants to better help their clients (e.g., “learning to help seniors ask ques-tions”; “learning to deal w/health, help others”; “sim-ple steps could help clients/myself”). Of the remaining comments, a few expressed appreciation for the detail provided about how to coach, a few mentioned the value of role-playing, and several echoed the value of health literacy skills.

Fidelity of Health Literacy Coaching to Workshop Training

It was not feasible to engage in direct observation of coaching to ascertain the fidelity of coaching practice to the workshop curriculum. Rather, we depended on MOW client recall of coaching to index coach fidelity. To the extent that clients recalled details of their coach-ing that conformed to the training we administered to their MOW volunteer coaches, we could conclude that the coaching procedures discussed in the workshops had been absorbed and implemented by the workshop participants. The disadvantage of this method lies in the declining memory of older adult MOW clients. Nevertheless, when queried over the telephone at sev-eral points over the course of a year—229 such phone calls were made following clients’ self-reported health care appointments—93% of the preceding health liter-acy coaching events were recalled. Following 83% of coaching interactions, clients reported that they thought about “good questions for good health” during their subsequent medical appointments. At project posttest, 131 coached clients’ were administered a face-to-face interview, portions of which queried them about their experiences in being coached (among other measures). Recall of coaching practices ranged from 73% (pro-vided a calendar to record medical appointments) to 85% (received a bag containing health literacy para-phernalia). Seventy-eight percent recalled having been shown videos that modeled interactive health literacy.

>>DisCussion

MOW volunteers were selected to serve as health literacy coaches for homebound older adults because of their opportunities for repeated and trusted interaction with their “hardly reached” clients (Johnson, 2004). In a workshop and a subsequent booster session, volun-teers were trained to coach their clients in interactive health literacy, especially in preparing and asking questions at medical appointments. The training con-sisted of presentations about communicating with

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older adults, about health literacy, and about the pro-cess of conducting the coaching regimen. Participants viewed videos modeling interactive health literacy behaviors between MOW clients and their providers, and also modeling an ideal health literacy coaching session. Participants also engaged in structured discus-sions and role-playing.

Results showed positive ratings for the workshops in terms of self-reported learning, utility, quality of plan-ning, and quality of the workshop execution. Participants generally found the workshop to be practi-cal, engaging, innovative, and detailed. Their open-ended remarks about highlights of the workshop focused especially on the value of the communication component, the videos, and enhancement of volun-teers’ ability to help their clients. Evidence of learning was evinced by scores on a test of material presented about memory and medication (68% correct on aver-age) and increased accuracy (83% correct at posttest) in naming the three specific questions to ask health pro-viders that were emphasized in the training. Based on client interviews and posttests, fidelity of the coaching behaviors to the workshop curriculum appeared to be high. Clients recalled the coaching sessions and reported that they used the information in their subse-quent interactions with their health care providers. These results complement those of the earlier “Maximizing Brief Encounters” project in Oregon (Johnson, 2004), which did not focus on health literacy but provided the model for enlisting MOW volunteers for health surveillance and communication with home-bound older adults. Participants in that earlier model likewise offered positive evaluations and demonstrated learning.

Programs to improve health literacy among vulner-able, “hardly reached” populations are especially pro-pitious at a time when health reform in the United States is demanding patient-centered and affordable care (Koh et al., 2012). Our efforts to train community members as health literacy coaches are well aligned with the Department of Health and Human Services’ National Action Plan to Improve Health Literacy. Goal 4 of the plan explicitly recognizes the central role com-munities play in supporting efforts to improve health literacy. Community-based volunteer social services workers are natural allies in efforts to bolster clients’ health status (Aldrich & Benson, 2008; Beattie et al., 2003), including improving health literacy. As part of an older adult’s social network, community members are uniquely positioned to serve as trusted health informa-tion resources to older adults in their community. For community-dwelling older adults, regular visits by com-munity volunteers constitute crucial social interactions.

The kind of social contact with which coaches deliv-ered health literacy information along with nutrition in this project is particularly important for isolated home-bound and rural older adults (Cornwall & Waite, 2009; Young et al., 2012). Thus, mobilizing community resources such as MOW that at once maintain older adults’ social networks and can inculcate health main-tenance skills makes eminent sense for bringing health interventions to the “hardly reached.”

The work described here can be a valuable resource to others wanting to leverage the power of trusted com-munity members in addressing health literacy in their community. Community volunteers, by their very nature, are ready and willing to serve members of their community. Our experience shows that by providing these volunteers with the training and materials they need, they are eager to add value to their volunteer experience by coaching for health literacy. Our online tool kit (http://chrc.uga.edu/research/toolkit/) provides easy access to the materials a community organization may need to implement a health literacy program.

Although language in the Affordable Care Act and other public health documents continues to refer to “hard-to-reach populations,” we believe that training programs such as the one described in this article indi-cate that vulnerable populations are in fact reachable when community assets are enlisted in creative ways for public health outreach. By partnering public health initiatives in health literacy and other areas with trusted community individuals and agencies, there is no reason why any population need be “hardly reached” (Freimuth & Metger, 1990).

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